1. AC Joint Excision
Mr Chris Roberts
Consultant Orthopaedic Surgeon
Ipswich Hospital NHS Trust
2nd Indian Watanabe meeting, Chennai

2. Anatomy
• Diarthrodial joint
• Two types of fibrocartilage discs :
complete partial (meniscoid)
• No function after 4th decade
• Nerve supply : axillary
suprascapular
lateral pectoral

3. Anatomy

4. Superior and Posterior
Acromioclavicular Ligaments
Coracoclavicular ligaments
(antero-posterior stability)
16mm 30mm
t c

5. Footprint of Superior ligament
Up to 17mm

6. ‘Normal’ x-rays
Urist 100 shoulders :
49% clavicle over-riding acromion
27% vertical
21% incongruent
3% clavicle under-riding acromion

7. Correct operation done correctly
Right reasons
Full excision
Safely

8. AC Joint Excision
•Indications:
– Symptomatic OA
– Painful ACJ
(osteolysis)
– Prominent inferior
osteophyte
•Beware:
– Instability

9. AC Joint Excision
OA of AC joint very
common
But rarely symptomatic

10. AC Joint Excision
OA of AC joint very common
But rarely symptomatic
SO
Excision based on clinical findings

11. Examination

12. Examination
Provocative tests

13. Most important test
Accurate ACJ intra-
articular injection,
ideally USS guided,
resulting in relief of
symptoms/signs

14. AC Joint Excision
Investigations
Specific X-rays - ↓ penetration
- 10-15º cephalic tilt
MRI - not routine
- other causes
Bone scan - rarely

15. ACJ excision options
•Open ACJ excision still
commonly performed
•Commonest
arthroscopic approach is
bursal
•2-superior portal ACJ
excision: some
advantages but
technically challenging

16. Set-up
• Beach chair/lateral decubitus
• Hypotensive anaesthesia
• Radio-frequency device
• 4.0 or 5.5mm acromionizer

17. Posterior viewing portal

18. Anterior working portal

19. Lateral and Neviaser viewing
portal

20. Work to a pattern
• Clear antero-inferior capsule and surrounding fat
• Ensure correct resection depth by excising antero-
inferior clavicle to depth of burr
• Excise remaining inferior clavicle to same depth
• Excise superior clavicle preserving superior
capsule
• Excise central bump

22. Inferior osteophyte without
symptoms
Co-plane osteophyte level with acromion
or
Excise whole depth of clavicle
Avoid excision part clavicle depth

23. Pitfalls
•Incomplete excision
– Posterior
– Superior osteophyte
•Instability

24. Summary
• Assess clinically – decision before
operation
• Vary portals for good view
• Work to a pattern
• Preserve postero-superior capsule

25. AC Joint Excision
Thank you